Health Records Request Letter

November 27, 2090

To: Ms. Sarah Lim
Medical Records Department
Springfield General Hospital
456 Health Way
Springfield, IL 62701

Dear Ms. Lim,

I am writing to formally request a copy of my health records under the Health Insurance Portability and Accountability Act (HIPAA). I would like to receive the following documents:

• Complete medical history and treatment records

• Lab results and imaging reports from January 1, 2090, to December 31, 2090

• Consultation notes and discharge summaries from all visits during that period

For verification purposes, my details are as follows:

• Full Name: John Doe

• Date of Birth: March 15, 2050

• Medical Record Number: 123456789

Please send the requested records to the address listed above. Alternatively, if electronic delivery is available, you may email them to my email address at [Your Email].

If there are any fees associated with processing this request, kindly inform me beforehand. I would appreciate it if you could confirm receipt of this letter and provide an estimated timeline for when I can expect to receive the requested documents.

Thank you for your attention to this matter. I look forward to your prompt response.

Sincerely,

[Your Name]

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